BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

Tuesday, April 29, 2014

BY RALPH BLUMThere has been a lot written about the
benefits to prostate cancer patients of eating mindfully. Boiled down to
simplest terms, the notion translates as “Just eat less.”I am always a bit uncertain when I read how
mice prosper on some regime or treatment. Like the diet known as “caloric
restriction,” which has all the normal healthy ingredients and food groups, but
contains 30 percent fewer calories than usual. A New York Times article of July 10, 2009 stated that “mice kept on
such a diet from birth have long been known to live up to 40 percent longer
than comparison mice fed normally.”Well and good. Further up the chain than
flatworms. But still a long step from human results with caloric restriction.
The next step was to use such a diet with rhesus monkeys to learn whether
primates responded the same way as rodents. However, since rhesus monkeys have
an average life span of 27 years and a maximum of 40, these experiments require
patience.Dietary restriction seems to set off an
ancient strategy written into all animal genomes, that when food is scarce
resources should be switched to tissue maintenance from breeding.The rhesus monkey experiment requires another
15 years before the last monkey is expected to die. An eon, compared to
flatworms, which have a life expectancy of about three weeks.Twenty years after the experiment began, two
studies, conducted by a team led by Ricki J. Colman and Richard Weindruch at
the University of Wisconsin, reported in Science
that the monkeys were showing many benefits, including significantly less
diabetes, cancer, and heart and brain disease. “These data demonstrate that
caloric restriction slows aging in a primate species,” the researchers wrote,
which makes it likely that one could expect the biology of caloric restriction
to produce similar benefits for humans.While caloric restriction holds great
promise, few people can keep to a diet with 30 percent fewer calories than
usual. So biologists have been looking for drugs that might mimic the effects
of caloric restriction, conferring the gain without the pain, so to speak. In
recent years researchers have had considerable success in identifying the
mechanisms by which cells detect the level of nutrients available to the body.
The goal is to find drugs or compounds that trick these mechanisms into
thinking that famine is at hand, hence the need for a severely restricted diet.One such compound is resveratrol, a substance
that can, apparently, duplicate in people some of the effects of caloric
restriction. A member of a group of plant compounds called polyphenols,
resveratrol is thought to have antioxidant properties that protect the body
against the kind of damage linked to increased risk for conditions, including
cancer since resveratrol is thought to limit the spread of cancer cells and
trigger the process of cancer cell death or apoptosis.The problem was that resveratrol, found
primarily in the skin of red grapes (other sources include peanuts and berries)
and, hence, in red wine, is present in quantities too small to have any effect,
unless you drank about three bottles at a sitting. I have long been a fan of
reveratrol, although I have despaired of acquiring enough of the compound to
have a measurable effect on my system.When
it comes to resveratrol supplements, there isn't any specific dosage
recommendation, and dosages can vary from supplement to supplement, although
they are typically far lower than the amounts that have been shown beneficial
in research studies. Most supplements contain 250 to 500 milligrams of
resveratrol. To get the equivalent dose used in some animal studies, you would
have to consume 2 grams of resveratrol (2,000 milligrams) or more a day. Not
impossible. And arguably not a risk.Now, Sirtris, a company based in Cambridge,
Mass., has developed several chemicals that mimic resveratrol and can be given
in concentrated doses. One such compound, the drug rapamycin, was reported to
significantly extend life span in elderly mice, though it is not yet clear
whether rapamycin sets off the same circuits as those that increase longevity
in caloric restriction when ingested by humans. But there’s hope!I remember when I was growing up, my Catholic
classmates, like Dicky Doyle, ate no meat on Fridays. I reckon that at the very
least, the meatless 24 hours gave their digestive systems a rest. Seen as a
mild form of caloric restriction, meatless Fridays might well have had an
impact on human longevity.Perhaps if I can find a copy of the Beverly
Hills High School alumnae, I can discover who is still around as we enter our
80s. And if they are still in possession of their faculties, perhaps I can
learn what and how they’ve been eating for the last half century.Meanwhile, there is evidence that those of us
who eat as our ancestors ate do better in avoiding or fighting a variety of
ills, prostate cancer among them.In my upcoming blogs, I will revisit the eating
habits of cave dwellers.

Tuesday, April 22, 2014

BY MARK SCHOLZ, MDRecently, our attention has been
directed at the overtreatment of low-grade prostate cancer.While PSA screening has been fingered as the problem,
overuse of random needle biopsies is the real culprit. Over a million men
undergo biopsies every year to address concerns about the possibility of underlying cancer. Few people realize, however, that random
biopsy reveals low-grade prostate cancer in
one out of five men in the general population—even if PSA is normal.

Most of these “cancers” are harmless. Even
so, it’s hardly surprising that patients with “cancer” want immediate
treatment.The words “low grade” or
“microscopic” can’t offset the instinctual fears generated by this venomous
word.Despite dire warnings about the
risks of treatment-induced impotence and incontinence—and reassurance from
experts that low-grade prostate cancer can be safely monitored—studies show
that 85% of men still throw caution to the wind and get treatment anyway.

Imaging
is “Blind” to Small Low-Grade Cancers

While latent prostate cancers are more
common, aggressive prostate cancer is also a reality. After all, 30,000 men die
every year of prostate cancer. Back when doctors believed that all types of prostate
cancer were universally dangerous, prostate imaging, which often misses small,
low-grade lesions, was deemed inadequate. However, now with a more modern
perspective we know that color Doppler ultrasound or multiparametric,
three-tesla MRI overlook low grade
disease while still detecting high-grade disease accurately.Imaging spares men the shock of an
unnecessary cancer diagnosis and unwarranted treatment.

Targeted
Rather than Random Biopsies

When an overtly suspicious lesion is
detected by imaging, a targeted biopsy
(a limited number of cores aimed directly at the lesion) is typically
recommended. Lesions that are biopsy-negative or show low-grade cancer can be
monitored without treatment.If
high-grade disease is diagnosed, further staging followed by counseling about
treatment is needed.

The doctor who reads the scan
summarizes his overall impression
which falls into one of three categories:

No evidence for high grade disease, no need for biopsy

A suspicious lesion is detected, a targeted biopsy is necessary

An ambiguous area is detected. Either a targeted biopsy can be considered or alternatively, ongoing monitoring with another scan in 6-12 months can be considered

When to
Biopsy Ambiguous Lesions

Imaging “sees” all sorts of things
besides cancer including scar tissue, areas of active prostatitis, and nodular
areas from BPH. Lesions of greater concern are located in the peripheral zone,
over a centimeter in size, bulge the prostate capsule or are associated with
increased blood flow or diffusion. An ambiguous lesion may require biopsy if a
subsequent scans show an enlarging lesion. Expert judgment that takes individual
patient characteristics into account comes into play during a discussion
between the patient and doctor about whether or not a targeted biopsy is
indicated.“Cross
Checking” Ambiguous LesionsColor Doppler ultrasound and
multiparametric MRI are complementary. In our experience the imaging findings
between these two modalities match 80% of the time. However in a minority of
cases one imaging modality illuminates a specific lesion more clearly.
Therefore, with ambiguous lesions using one modality, we usually consider
additional imaging with the other modality before recommending targeted biopsy.New
Technology Brings Growing PainsYou might think that new technological
advances would immediately revolutionize prostate cancer management. Not
necessarily. Many doctors simply don’t know what’s now available. Those that
are aware are often unacquainted with the full capabilities modern imaging can
achieve. And finally, even the well informed doctors may be reluctant to
venture outside their comfort zone to embrace imaging as a substitute for doing
a random biopsy.Final
ThoughtsLack of awareness about how random biopsy
leads to the over diagnosis of harmless, low grade cancers is resulting in a
100,000 men undergoing unnecessary surgery and radiation every year. Forgoing
PSA screening altogether is both foolish and dangerous. State-of-the-art
prostate imaging, not random biopsy, should be the first step in evaluating men
with elevated PSA levels. Join us in Long Beach, CA at Barnes & Noble Marina June 26, 2014 @ 7pm- Ask the Author: Mark Scholz, MD will be discussing his book, Invasion of the Prostate Snatchers and Men's Health. More June events and details here: https://groups.google.com/forum/#!topic/prostateoncology/H1AE5oeW2jc

Tuesday, April 15, 2014

In an essay entitled Complications:
Surgeon’s Notes on an Imperfect Science, Atul Gawande, surgeon, writer and
professor at Harvard Medical School wrote: “Just as there is an art to being a
doctor, there is an art to being a patient. You must choose wisely when to
submit and when to assert yourself.”

This advice is especially important if
you have just been diagnosed with prostate cancer. Because prostate cancer is
so common, and in most cases so slow growing, that to submit to any form of
radical treatment could be a huge mistake, and hugely detrimental to your
quality of life. Yet most doctors you consult will advocate some form of
radical treatment. It’s what they know, what they do. And it goes against the
grain for both doctors and patients alike not to treat cancer.

But prostate cancer is unique among
cancers because the mortality rate is so low. Autopsies reveal that more than
50% of older men have the disease, live with it, and die from something
else—sometimes without ever knowing they had a life threatening condition.
Furthermore, the life expectancy of men with recurrent prostate cancer
stretches out well past a decade. And yet the radical prostatectomy, one of the
most complex and challenging surgeries because the prostate is located in
absolutely the wrong place for a simple surgical solution, is still the most
widely recommended treatment option. It is also the most unnecessary, and the
one most likely to leave you incontinent and/or impotent.

My own experience with urologists has
not been a happy one. Twenty years ago, a doctor who wanted nothing but patient
compliance, told me that if I did not agree to immediate surgery I would be
dead in two years. His recommendation and prognosis were not only wrong, but in
my opinion violated the ancient medical precept incorporated in the Hippocratic
Oath: “First do no harm.” Fortunately I
was not the kind of patient to be easily intimidated.

A significant part of any doctor’s job
is to create a relationship based on trust, confidence and hope. And as
patients, our job is to put ourselves in charge of our recovery. It is
our job to do the research, and give ourselves permission to say “No” if we
feel the recommended treatment—for what ever reason, or simply instinct— is not
right for us.My decision not to be
intimidated by what, in effect, was a death threat, but to monitor the cancer
and take the time to educate myself, has given me many years of quality time
with my wife that almost certainly would have been lost or diminished if I had
committed to immediate surgery.

Doctors have busy lives. They believe
in what they do. But often they tend to treat the disease and not the patient.
Traditionally we’re encouraged to go along with whatever they recommend, and
asking questions, or refusing to follow advice is unpopular. But this
passive attitude does not serve us well. The feisty, “difficult,” assertive
patient, the one who challenges the doctor, is the one who has the best
outcome.

Tuesday, April 8, 2014

MARK SCHOLZ, MDClinical
studies are primarily performed on men with advanced prostate cancer (the Royal
Shade of Blue). Why? The FDA.FDA only approves new drugs when survival is
proven to be prolonged compared to similar men treated with a placebo. The
FDA’s insistence on a survival endpoint forces pharmaceutical companies to
limit their research to men with a short life expectancy. If survival has to be
the endpoint and the study participants live a long time, the cost of
performing the study goes up exponentially.Undergoing
experimental therapy with a new medication is reasonable consideration when
standard treatment is either no longer working or is causing unacceptable side
effects.However, it’s rare for doctors
to recommend an experimental medication before other FDA-approved drugs on the
market have been tried.The commercially
available treatments already proven to extend survival are Lupron, Provenge,
Xtandi, Zytiga, Xofigo, Taxotere and Jevtana.Getting Involved in a Trial
Can Be Challenging

Eligibility requirements for participation can be rigorous.
Trials have carefully specified pretreatment and health status criteria: Eligibility
may be denied if the patient is either too sick or not sick enough, if there is
too much previous treatment or not enough previous treatment. Criteria are pre-specified
so that the final results of the trial are not skewed by a lack of uniformity among
patients.Other requirements designed to
achieve trial uniformity include stopping all other anti-cancer medications and
the use of placebos, both of which at times may be at variance with a patient’s
best interest.

An additional challenge is finding the
right trial that matches a patient’s need. The clinical trials landscape changes quickly.New trials are initiated with limited fanfare
and close as soon as they have met their pre-specified number of participants. Trials
available at one center may not be so at another.Another difficulty patient’s face is how to
determine the effectiveness of a prospective study drug. Is it likely to work
or not? Due to a study drug’s newness,
its functional characteristics are often unclear to patients and doctors alike.

There are different types of study designs to consider
each with different goals.Phase I studies, for example, are primarily
designed to learn more about a drug’s side effects. Phase I studies sequentially
escalate medication dosages up to determine the point of dosage intolerability.
Phase II studies treat a group of patients at a fixed dosage to get a
preliminary sense of a drug’s response rates. Phase III studies are the final
step that leads up to FDA approval.Phase
III trials are the placebo-controlled trials.

The Business of Clinical
Trials

Patients contemplating participation in a clinical trial
should be aware that the clinical trial world functions like a business.It’s funded primarily by the pharmaceutical
industry. As such, doctors working in academia are highly motivated to find participants
in their research.If trials are not
completed in a timely fashion funding for new trials will be harder to come by
in the future.

Participating in a clinical trial has become more
attractive over the last ten years as the pharmaceutical industry has made
significant strides toward understanding cancer.Now that they have access to cancer “blueprints” it’s feasible for
brilliant biochemists to design “software patches,” new drugs that are far more
effective and far less toxic than what has been traditionally available. However, patients need be careful
they don’t mistake a “new” drug for being an “effective” drug. Despite the tremendous advances in research,
most phase I and II drugs still fail to meet minimum standards of clinical
effectiveness and never even advance to phase III testing. Sadly, many of the
potential prostate drugs that have been tested in Phase III studies over the
last ten years have failed to meet the FDA minimum threshold of showing a
survival advantage.

Tuesday, April 1, 2014

By
2013, I had lived with prostate cancer for almost 25years without submitting to any form of radical treatment. I was
fortunate that my cancer was the non-aggressive, slow moving variety. And over
the years I became a strong advocate of a “Die with it not from it” policy.I
learned early on that a “Whatever you say, doc,” attitude can be dangerous, and
I knew that the longer I could simply monitor the cancer and use the time to
educate myself about the disease, the better off I would be. However, the main
reason I resisted radical treatment was the book Mark Scholz and I wrote with
the sub-title: “No More Unnecessary Biopsies, Radical Treatment or Loss ofSexual Potency.” I reckoned I’d better practice what I preached.Then,
a little over a year ago, when my PSA suddenly spiked to 26 for no reason I
could determine (like BPH or an infection), I figured the cancer was finally on
the move. And maybe, after all these years, my immune system was no longer the
staunch ally it had been. Mark was reassuring. My cancer hadn’t changed—it was
still the non-aggressive type. Which meant the odds of surviving were pretty
much in my favor if I decided not to submit to treatment. Still, “To treat or
not to treat” remained the question.After
determining that the cancer hadn’t spread to my lymph system or to my bones
(big relief there!), I couldn’t help wondering if perhaps I was pushing my luck
by sticking to my credo. And to tell the truth, I was getting tired of living
with cancer. So as I am no fan of surgery, and anyway at my age (81) it was not
an option, I decided to go for a cure with IMRT, Intensity Modulated Radiation
Therapy.It
is now almost five months since I completed 45 sessions of IMRT, and I could
not be more pleased with the results. At first, I was dismayed to see a rather snail-slow
descent of my PSA. Then I learned—and this is the really big news—that cell
death, or apoptosis, continues after treatment for another year to a year and a
half. According to Lisa Chaiken, MD, an admirable and patient teacher, who is
in charge of St. Johns Hospital’s IMRT program, “The cancer cells turn over
slowly. More and more die off with the passage of time. There is an immediate
impact of the radiation—the damage, is done—but the process takes time."And
get this: the cells only die when the time comes for them to divide! In trying
to participate in the creative process of replication, cell death, apoptosis,
is the result.The cancerous cells are
actually committing suicide: How’s that for irony?To
confirm with visual evidence what is taking place, I’ve been to see radiologist
Duke Bahn, MD and compared his various ultrasound images of my prostate: the
multiple red tributaries indicating angiogenesis (the flow of new blood to the
tumor), once as thick as a busy river delta, are now reduced to a scattered few!An
unexpected bonus for me from undergoing IMRT is a new understanding of PSA
function, about which I was always uncertain in the past. Now that I understand
the process, the behavior of my PSA—post-treatment—makes total sense: As the
cancerous cells die off, the PSA falls. I am now almost five months post
treatment, and my PSA has dropped from 26 to 17 to 7.8 and a week ago, in the
most recent PSA, to a gratifying 2.8! A level I haven’t seen in a quarter of a
century!Technically speaking, I still have prostate
cancer. But my cancer is terminally feeble, itself waiting for the final cut by
the Grim Reaper of cancers.IMRT is truly the gift that keeps on giving!

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PROSTATE SNATCHER VIDEOS

MARK SCHOLZ, MD

Mark Scholz, MD is board certified in medical oncology and internal medicine. He has been treating men with prostate cancer exclusively since 1995. He is the Medical Director of Prostate Oncology Specialists, Inc., and Executive Director of the Prostate Cancer Research Institute. He is an acknowledged expert on management and treatment for prostate cancer using hormone intervention, immunotherapy, chemotherapy and angiogenesis as well as vitamin, herbal and other forms of lifestyle counseling. His affiliations include St. John's Health Center, Marina del Rey Hospital and others. Dr. Scholz also served as an associate clinical professor in the department of Oncology at USC School of Medicine. Dr. Scholz volunteers for the Internet list “Patient to Physician,” found via Resources at www.pcri.org . You may also find current posts on twitter. www.twitter.com/markscholzmd

RALPH H. BLUM

Ralph H. Blum is a cultural anthropologist and author, graduated Phi Beta Kappa from Harvard University with a degree in Russian Studies. His reporting from the Soviet Union, the first of its kind for The New Yorker (1961—1965), included two three-part series on Russian cultural life. He has written for various magazines, among them Reader’s Digest, Cosmopolitan, and Vogue. Blum has published three novels and five nonfiction books. He has been living with prostate cancer, without radical intervention, for twenty years.

PROSTATE ONCOLOGY SPECIALISTS

Established in 1995, Prostate Oncology Specialists has earned national acclaim for its comprehensive approach to prostate cancer prevention and management. Under the direction of Medical Director Mark Scholz, M.D., Prostate Oncology Specialists employs a highly skilled team of physicians trained in oncology, radiology, hematology, and internal medicine who treat all stages of prostate cancer. Prostate Oncology Specialists are not wedded to any single therapy for prostate cancer, but rather advocate the exploration of treatment options that are customized and tailored to the unique needs of each individual patient. Treatments employed include active surveillance, testosterone deprivation, partial cryotherapy, seed implantation, intensity-modulated radiation, and surgery. Prostate Oncology Specialists’ ongoing mission is to uncover new medical breakthroughs in the treatment and management of prostate cancer.

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